Like so many other people in South Africa, Dr Nicholas Crisp has had his own close encounter with the disease. Over the past six weeks, Covid-19 left his wife — who is almost certain she contracted the virus while queuing for an identity document in a Home Affairs office — and daughters severely ill and bedridden. All have now recovered fully. Crisp himself remains asymptomatic, although he missed his second Pfizer jab appointment last week due to work pressures.

“My one daughter’s husband has a comorbidity, so he had to stay far away from her, and my other daughter (both in their 30s), got it from her boyfriend. It hit her hard. I also have many friends and close colleagues who’ve died from Covid-19. Nobody’s getting away with it any more. Just about everybody has similar stories,” he tells Spotlight.

The veteran public health specialist is also in charge of National Health Insurance (NHI) at the Department of Health, but it is the vaccine roll-out that has been his top priority in recent months.

Vaccine flow interrupted 

“Our biggest current problem is we don’t know when the latest 1.4 million Johnson and Johnson (J&J) consignment that was due on Monday will arrive. We’ll now run out of vaccines this week.”

He was speaking to Spotlight on Wednesday, 28 July.

“Even the routinely arriving Pfizer consignment that came in last Sunday, (25 July), was smaller than usual at 968,760 doses. Yesterday, we averaged 225,000 jabs nationally, which is disappointing because we’re running out of stock. Some sites have been unable to gear up,” he says. 

Crisp says the current vaccination target is 250,000 jabs per day, ramping up to 300,000 daily when the J&J consignment eventually arrives. Some 35 million South Africans are targeted for “the jab” by Christmas.

The 1.4 million J&J doses did eventually arrive, as confirmed by Crisp during a Department of Health media conference on Friday morning (Crisp starts speaking around 15 minutes in).

Asked what caused the delay, Crisp hesitates before replying, “There are too many moving parts to give you a single answer.”

He says just under seven million doses of vaccine had been administered by Wednesday at all 3,000 vaccination points, including outreach projects, satellite clinics, pop-ups and mobile clinics.

On the impact of the unrest and looting in KwaZulu-Natal and Gauteng that began in the second week of July, he says that the Covid-19 vaccination campaign suffered the least among all the hugely disrupted healthcare services. Of the 2.5 million doses in circulation at the time, just 47,000 were lost or destroyed.

“Even in (worst-hit) KwaZulu-Natal we just happened to be distributing in many places that were not being ransacked. Those stocks that were en route were quickly redistributed to non-affected provinces. The unrest also led to a drop in demand. People couldn’t move, with no taxis or fuel and roadblocks, so we felt it safer to just stop the entire programme in KZN. Once the violence was over, the vax teams bounced back very quickly, especially the public sector. Unfortunately, the private sector was hit far harder, with 12 pharmacies trashed and the main United Pharmaceutical Distributors warehouse in Durban destroyed,” he says. 

Unpacking the roll-out

He outlines four main current roll-out streams; public sector vaccination, essential public services (including healthcare workers), the basic education sector, people in the social development sector in direct contact with children and patients, and the security cluster. This last cluster included all SA Revenue Services staff and Home Affairs officials at border posts and airports.

“The object is to keep the government systems running in designated priority programmes. Those are all but finished now with just Correctional Services and the SA Police Service roll-outs still running,” he says.

Other current roll-outs included the higher education sector (35 universities and colleges), media workers, the taxi industry, plus workplaces with 4,000 people or more. “A number of employers have 4,000 staff or more, but they’re spread across the entire retail sector and that’s been much more difficult to manage and far slower,” he said.

Another vaccine roll-out stream, termed “surge or rolling and roving capacity”, involves mass vaccination sites like metropolitan, convention or municipal centres. There are also mobile clinics and outreach sites with the main focus on pension pay-out points, but also embracing congregate settings such as old age homes and centres for people living with disabilities.

“When pension days are over, we go from village to village, targeting older people and using loud hailers in rural areas. All of this is happening at the same time,” Crisp says. 

Vaccination on weekends

The Department of Health has been widely criticised for the low numbers of vaccinations done on weekends.

Crisp says the health system is struggling to find vaccination staff to work weekends, adding, “there are literally no more people to fill more shifts in many places. Health Science students and volunteers are stepping in, but it remains a challenge.”

He argues that for those currently in harness, time off to avoid burnout and exhaustion is crucial.

He says the national health department advertised for external service providers to manage vaccination sites, but the response was “extremely poor”. “Also, during the Covid-19 waves (surges), the hospitals soak up all the spare qualified people,” he adds.

Electronic Vaccination Data System issues

South Africa’s Electronic Vaccination Data System (EVDS) has at times been criticised for, among other things, scheduling vaccinations far from people’s homes.

“The primary function of the EVDS is to act as an electronic patient record,” says Crisp. “You fill it in when you can get to the portal. If you cannot manage, then someone helps you. Then there is a booking system or scheduling. This is controlled by vaccination site managers who must match their resources, (vaccines, staff, and vaccination points), to the demand. The EVDS searches for people in the queues to add to sites. The challenge, however, is that it uses the perimeter of the lowest address (town, suburb, etc) to seek the site nearest to you. When there were few sites (there are now 3,000), it had to look far afield. As these site numbers grew, it found nearer sites. It’s crucial you enter a clear and detailed address because if, for example, you enter Tshwane instead of Arcadia as your address, it sees Sandton and Mamelodi as equally near to you.”

But it may well be that the automatic scheduling feature is not optimal, he concedes.

Fielding curveballs

Crisp says one of his biggest headaches was a “tag on” programme involving travellers.

Prospective overseas travellers between the ages of 18 and 35 could write to secure permission for a jab (most registered to study overseas), but many overseas countries insisted on them having a specific vaccination, (Moderna for example, which South Africa doesn’t have).

“I get dozens of letters from all over with the strangest things. We have to politely tell them we can’t accommodate them. We can’t have other countries telling us what vaccines to buy. One or two countries are also insisting on an electronic certificate that proves vaccination,” he says.

“Aspirant travellers get irate and say we’re denying them their rights, but we have 60 million South Africans to look after and our own policies. We’re going to stop this service from 1 September. This isn’t a health matter, it is political and diplomatic,” he adds.

Crisp also reveals that his department is urgently trying to set up a mechanism for undocumented people. (Spotlight this week reported on the difficulties faced by people who are homeless and who do not have identification documents.)

Another problem was the dozens of lobby and support groups with urgent and legitimate, but logistically complex operational requests, like vaccination for pregnant women, patients on renal dialysis, or those with multiple sclerosis.

“It’s too complicated to do. It can’t just happen on a Friday. It doesn’t work like that. They must still register. Remember, people of 60 and older have a four times higher risk than younger folk with comorbidities. We have to get to the most vulnerable first and as quickly as possible in order to take pressure off the healthcare system,” he stresses.

A second objective of the roll-out, he says, is to break community transmission and reach herd immunity, “even though we don’t yet fully understand how this works with this virus”.

‘Doing well above average’

Crisp appealed to 18 to 35-year-olds to help their more vulnerable parents and grandparents get vaccinated first, saying he was concerned the younger group would “flood the system”.

He says he has been inundated with complaints following President Cyril Ramaphosa having encouraged “walk-in” vaccinations during his fortnightly televised address.

“Walk-ins are extremely difficult to manage. The president just gave the headlines, not the whole policy. You can’t just walk in and stand in front of somebody who’s taken the trouble to make a reservation. Protecting people of 60 years and older protects us all,” he says.

Crisp appeals for patience and says the walk-in policy was aimed at using up vaccines left over by no-shows. Addressing the public frustration with several week-long delays between registration and vaccination notification, he adds, “It’s hard for people to understand that a queue of 12 million people, two metres apart, stretches for 24,000 km. Even distributed to 3,000 sites, that queue is still pretty long.”

“This is bigger than anything this country has ever attempted and called for a massive response in a few short months. We had to fight to get vaccines in a globally aggressive market and the virus kept us all guessing. Compared to other countries, we’re doing well above average. What we need is a nation that recognises that everyone’s survival is dependent on everyone’s participation.” DM

This article was produced by Spotlight — health journalism in the public interest.